49 Interventions to relieve ED crowding by older adults CHAPTER 3 Two reviewers (G.H. and J.v.H.) independently assessed inclusion eligibility of the retrieved studies using the search strategy. The initial selection for inclusion was based on the title and abstract of the study. When the title and abstract provided insufficient information to determine the relevance, a full-text copy of the article was retrieved and reviewed. For the final selection, a full-text copy of the study was examined to determine whether it fulfilled the inclusion criteria. Disagreement about inclusion was solved by discussion. When no consensus was achieved, a third reviewer (Y.S.) made the final decision. Data extraction Two reviewers (G.H. and J.v.H.) independently extracted data from included studies. A standardized form was used to ensure consistency of data extraction. The following data were extracted from individual studies: country, publication year, study design, study setting, population characteristics, sample size, intervention details and outcomes of interest. Table 1 Direct and indirect measures of crowding in the emergency department Direct measures Indirect measures Input Throughput Output Ambulance diversion1 Occupancy level5 Boarding time9 ED staff stress level11 Waiting time2 Time to consultation6 Boarding count10 Return visits12 Waiting count3 Time to ED room/ bed placement7 Leaves without being seen4 Length of stay8 1 EDs diverting ambulances due to capacity problems. 2 Time between arrival on the ED and initial triage. 3 Number, percentage or mean of patients in the ED waiting room. 4 Patient leaves of the ED before start or completion of the treatment. 5 Volume of patients in the ED compared to the number of officially designated ED spaces, waiting or treatment rooms. 6 Time between registration at the ED and the first visit of an emergency physician or relevant subspecialist (e.g., geriatrician). 7 Time between ED registration or initial triage and placement in an ED treatment room or bed. 8 Time between arrival on the ED and discharge, admittance on a ward or death. 9 Time patients are hold in the ED after the admission decision. 10 Number, percentage or mean of patients in the ED after the admission decision. 11 Work-related feelings of stress (e.g., fatigue, burnout, being rushed) by emergency care physicians and nurses. 12 ED visits after index visit which may be the consequence of patient leaves without being seen or poor discharge due to time restraints and limited possibilities to arrange appropriate follow-up care.
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